By Becky Carney, MSPT1; Jeanette Ruby, MD1; Amanda Glazar, PhD, CHCP2; Michael Lemon, MBA, FACEHP, CHCP2; David Wyles, MD3; Bruce Packett4; Mandy Altman, MPA, CCHP5
1Integritas Communications, Hoboken, NJ; 2Postgraduate Institute for Medicine, Englewood, CO; 3University of Colorado School of Medicine, Denver, CO; 4American Academy of HIV Medicine, Washington, DC; 5National Hepatitis Corrections Network, Seattle, WA.
BLOCK HIV/HCV, a continuing medical education (CME)/continuing education (CE)-certified 2018 educational initiative jointly provided by Integritas Communications and the Postgraduate Institute for Medicine (PIM), was designed as a multifaceted regional meeting series to address the educational gaps and needs associated with effective HCV treatment within high-risk populations. The goal of the program, as reflected in its structure, was to provide a forum for clinician and nonclinician stakeholders involved in the identification, engagement, treatment and support of persons with HCV or HIV/HCV coinfection. This novel approach was intended to facilitate stakeholders’ collaborative formulation of best regional strategies and tactics for improving access to care.
Background and Impetus
Convergence of the human immunodeficiency virus (HIV) and hepatitis C virus (HCV) epidemics is a widespread clinical and socioeconomic phenomenon — or syndemic — of growing proportion within overlapping at-risk populations. Demographically, the face of HCV has shifted over the last decade toward a younger, non-urban population of people who inject drugs (PWID) in parallel with the opioid crisis. Impacted communities often face high rates of poverty and limited access to medical care. Yet, HCV and the HIV/HCV syndemic are, to a large extent, invisible or underrecognized.1,2
The asymptomatic nature of HCV prior to advanced liver disease — coupled with inadequate screening practices — sets the stage for low rates of HCV treatment. Moreover, clinicians’ and payors’ reluctance to treat HCV in past or current injection drug users compounds inaction, thereby leading to a higher incidence of both progressive liver damage and unchecked viral transmission. It is now epidemiologically imperative, however, that providers become clinically competent in the timely detection and treatment of HCV monoinfection and HCV in HIV-infected persons.
This raises the stakes for effective education and collaboration. Community-based HCV treaters and stakeholders — clinicians and non-clinicians — need not only education on the efficacy of current direct-acting antiviral (DAA) regimens in achieving HCV cure, but also on humanistic and pragmatic harm-reduction–informed approaches to psychosocial barriers impeding HCV treatment.3,4 Further, HIV/HCV stakeholders need encouragement to step up to clinic- or community-based roles in addressing structural barriers to HCV care and cure within these vulnerable populations. Critically, community-based action also includes local- and state-level advocacy for removal of nonevidence-based HCV-treatment restrictions.5 These ambitious objectives necessitate engagement of key collaborators to ensure the initiative’s success.
Collaboration: Key to Reaching and Impacting a Diverse Target Audience
Collaboration was pursued with organizations having a clear understanding of and access to the intended interprofessional mix of learners and/or expertise with regard to specific patient populations, regional policies and barriers, and community-based advocacy. The educational providers sought to leverage readily available resources and collaborate on two levels: primary, core, partnerships established during the grant development phase with national organizations and meeting-specific partnerships determined postfunding (Table 1). This approach provided both structure and the flexibility to add contributors for each program site.
Primary partnerships were established with the American Academy of HIV Medicine (AAHIVM)5 and the National Hepatitis Corrections Network (NHCN).6,7 AAHIVM, the largest organization of HIV providers, participated in the program’s faculty selection and content validation process. NHCN has unique expertise related to the challenges of identifying and treating HCV in jails and prisons. Its knowledge of correctional health system structures and regulations, ongoing educational efforts and access to a nationwide network of correctional-care stakeholders provided critically needed competencies. These organizations’ expertise and national recognition guided content development and enhanced faculty recruitment.
Secondary partnerships arose from expert recommendations and grassroots inquiries following program location selection. Identification of BLOCK sites was based on HCV-related epidemiology and demographics, local expertise in HCV care and substance use disorder treatment, and resource availability. Resources considered included regional academic buy-in and support, potential collaborators and local networking infrastructure. Critically, access to DAA therapies was assessed in terms of Medicaid restrictions, as published by the Center for Health Law and Policy Innovation and the National Viral Hepatitis Roundtable.5 The three sites chosen for 2018 BLOCK HIV/HCV programs were Charleston, West Virginia (WV); Boston, Massachusetts (MA); and Atlanta, Georgia (GA). Charleston represents an economically depressed rural region with high rates of HCV and opioid use disorder. Boston, a highly resourced, academically advantaged urban center with broad reach throughout the state, represents a region with high rates of HIV/HCV coinfection. Atlanta, a rapidly growing southeastern hub, represents a mixed urban/nonurban region with extension into rural, underserved areas.
Secondary partners included local healthcare networks, community HCV and HIV advocacy groups, local and regional governmental agencies and policy organizations, law enforcement and corrections, and faith-based and secular service-provider organizations. These collaborations were leveraged locally to ensure the engagement of a multidisciplinary participant base that would include medical professionals — HIV and/or HCV treaters and referrers — from community, corrections and academic settings; pharmacists; patient-support providers, including case managers, social workers and patient educators/navigators; community-based HCV/HIV advocates; governmental-agency representatives; and payors. A robust mix of participants was ultimately engaged for each of the three sites and was a key to the initiative’s success. Of the eight secondary partners, collaboration with the American Liver Foundation (ALF) was notable, especially in Boston.8 There, through established relationships with local organizations, ALF facilitated not only the involvement of diverse stakeholders that optimized community-based action plans, but also cost-efficient and convenient meeting logistics.
Table 1. Key Collaborators
The formulation of educational strategies, tactics and content addressed the inherent challenges of shaping content for — and measuring outcomes among — interprofessional audiences in demographically distinct regions. Crucial to site-specific development, the following parameters were taken into account:
- Interdisciplinary participation: clinical vs nonclinical; direct vs indirect stakeholder
- Varying local stages of HCV care implementation: current to aspirational
- Varying state and local level restrictions on access to HCV treatment
While aspects of the BLOCK curriculum were modified according to each site’s characteristics, the initiative’s overarching goal informed the core curriculum topics across locales:
- The epidemiologic imperative to identify and treat persons with chronic HCV
- The HCV care continuum and the current state of HCV treatment
- Feasibility, efficacy and safety of HCV treatment in key populations: PWID and men who have sex with
- HCV in corrections
- Harm-reduction principles, practices and programs
- Community-based strategies to optimize linkage to and retention in care, achievement of HCV cure and prevention of postcure reinfection
Key Program Tactic: Small-Group, Cross-Disciplinary Breakout Sessions
To facilitate community engagement and cross-disciplinary collaboration, each program featured a small-group breakout session. Groups, led by community-based leaders, advocates and subject-matter experts, were configured to have representation from all key stakeholder groups. Each breakout group was tasked with identifying current barriers, opportunities and achievable action items for advancing HCV care within their communities. Following each program’s breakout session, group leaders joined the faculty in presenting their insights and action items to a plenary session moderated by the program chair. As described further in the next section, the workshop output was remarkable (Table 2). This model moved the educational needle from you should do this to we will do this!
To extend participants’ learning and support, BLOCK coordinators procured and/or developed Action and Advocacy materials and resources that were disseminated to participants and other interested parties via an online Clinical Resource Center.
Outcomes Assessment: Design and Findings
Educational outcomes measurements were designed in accordance with prevailing CME standards. Pre-activity and post-activity surveys were customized for participants’ roles (HCV and/or HIV treaters vs nontreaters) to ensure data relevance.
Significant post-activity gains in knowledge were demonstrated at all program sites, as evidenced by a 163% average increase over baseline in key knowledge areas: HCV epidemiology, management of HIV/HCV coinfection, and effective approaches to HCV treatment barriers. Strong intention to change practices was demonstrated by 99% of participants planning to now screen for HCV in HIV+ patients and an overall 78% reporting that they will change their clinical or advocacy activities based on information presented.
A composite 97% increase over baseline was seen in individuals’ confidence in their own abilities to actively address barriers to HCV care within their practice sites. A lesser increase over baseline (43%) was demonstrated in participants’ confidence in their communities’/healthcare networks’ abilities to collectively reduce barriers. Site-to-site variability in both self- and collective-efficacy may reflect local healthcare infrastructure, resources and geographic challenges.
Figure: Key BLOCK Outcomes
aP≤0.02 for selected pre- and posttest questions; bBased on evaluation data, n=110; cBased on ARS data for the 2 questions top to bottom: n=111 pre, 69 post; n=78 pre, 55 post; dARS data, n=70 pre, 81 post; eBased on ARS data for the 2 items top to bottom: n=111 pre, 93 post; n=84 pre, 93 post.
The BLOCK initiative achieved documented success across a spectrum of traditional and innovative CME/CE measures. Individual and collective intentions to advocate and collaborate, as demonstrated on-site, transcend typical measures of educational impact (Table 2). As examples of this enthusiasm, the Boston and West Virginia meetings facilitated sharing of existing resources among participants, ad hoc presentation of available grant dollars for expanding education and capacity-building, and new partnerships between organizations with similar goals that were previously unaware of each other. The BLOCK events truly set the stage for local long-term impact benefitting HCV and HIV/HCV-coinfected patient populations.
Table 2. Small-Group Action and Advocacy Outcomes: Laying the groundwork for Level 5 outcomes
AETC, AIDS Education and Training Centers; DPH, Department of Public Health; ECHO, Extension for Community Healthcare Outcomes; EHR, electronic health records; MAT, medication-assisted treatment
Follow-up surveys distributed four months after each event were designed to measure both individual and collective efforts and progress in addressing the community-based action items (Level 5 outcomes; full data set pending).
Building on Success
Having established the feasibility and reproducibility of an educational model that facilitates local collaboration to expand and enhance HCV services, the BLOCK developers are now focusing on growth of the initiative. Both successes and lessons learned have been leveraged to secure additional funding, broaden the collaborative base and expand the program’s educational impact across five additional program sites in 2019. Recognition by the Alliance adds value to the BLOCK program’s efforts to share this collaborative model and is greatly appreciated.
- Morano JP, Gibson BA, Altice FL. The burgeoning HIV/HCV syndemic in the urban Northeast: HCV, HIV, and HIV/HCV coinfection in an urban setting. PLoS One. 2013;8(5):e64321.
- Perlman DC, Jordan AE. The syndemic of opioid misuse, overdose, HCV, and HIV: structural-level causes and interventions. Curr HIV/AIDS Rep. 2018;15(2):96-112.
- American Association for the Study of Liver Diseases/Infectious Diseases Society of America. HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C. Last updated 2018. https://www.hcvguidelines.org/.
- Harm Reduction Coalition. https://harmreduction.org/.
- Center for Health Law and Policy Innovation/National Viral Hepatitis Roundtable. Hepatitis C: State of Medicaid Access. Last updated 2018. https://stateofhepc.org/.
- American Academy of HIV Medicine. https://aahivm.org/.
- National Hepatitis Corrections Network. http://www.hcvinprison.org/.
- American Liver Foundation. https://liverfoundation.org/.